Impingement syndrome is a complex of interrelated and interdependent dysfunctions of the muscular and tendon-muscular apparatus of the shoulder joint.
Impingement syndrome is a complex of interrelated and interdependent dysfunctions of the muscular and tendon-muscular apparatus of the shoulder joint. The leading cause of such disorders is disease and damage to the rotator cuffs. The term “impingement syndrome” belongs to the American surgeon CS Neer and dates back to 1972.
External impingement syndrome is pathological changes in the soft tissue structures surrounding the shoulder joint. Some orthopedists distinguish “internal impingement syndrome” - a posterosuperior version of the syndrome associated with a rupture of the articular labrum; it often develops in athletes.
Inflammation of the bursa and its hypertrophy lead to a decrease in the subacromial space and pain when moving the arms above the head. Hypertrophy of the coracoacromial ligament is also a cause of decreased subacromial space and subsequent impingement .
Impingement syndrome is a common cause of shoulder that limits daily activities and sports activities. The pain resulting from impingement is localized in the area of the anterior outer part of the acromion process.
Patient complaints
Patients often note a gradual increase in pathological manifestations in the shoulder joint , which appear when actively working above the head or threading an arm through a coat. Weakness and limitation of movements in the shoulder joint often occur due to pain. A number of patients complain of sudden pain when exposed to trauma or learning a new sport. Patients often report pain at night and experience discomfort if they try to sleep on their sore shoulder. The range of motion sometimes decreases until a “frozen” shoulder forms.
Cost of treatment
| Surgical treatment | Cost, rub | Included in cost |
| Arthroscopic subacromial decompression of the shoulder joint | 65,000 RUR. |
|
The final cost of the operation can be calculated during a face-to-face consultation with our specialists.
Clinical examination
In order for the clinical examination to be comprehensive, the patient must be wearing a shirt, which will allow the neck and shoulders to be examined and the condition of the muscles to be assessed. The examination begins with the cervical spine and the upper extremity girdle. Restriction of movements in the cervical spine, pain that occurs during provoking tests and radiates to the shoulder region may be signs of pathological changes in the tissues of the neck and should not be mistakenly regarded as manifestations of impingement syndrome . The contours of the shoulder joint and the condition of the muscles should be compared with the opposite side, noting signs of atrophy and changes in the contours of the shoulder girdle. These signs, determined at rest, may indicate the neurological nature of the movement disorder in the shoulder joint, which leads to the development of secondary impingement syndrome . Against the background of pain, there is a limitation of active anterior flexion and abduction of the shoulder.
Diagnostic tests
Neer test
It is considered positive if pain at the anterior and outer edge of the acromion occurs when the examiner stabilizes the scapula and performs passive anterior flexion of the shoulder during internal rotation.
The Hawkins-Kennedy test
is considered positive if pain occurs with anterior flexion of the shoulder to 90° and slight internal rotation.
Test "Painful arc"
considered positive when pain occurs between 60° and 120° during shoulder abduction.
Infraspinatus muscle test
is considered positive if, due to weakness and pain, the patient cannot resist or there is a symptom of lag in external rotation. When performing the test, the arm is located along the body and bent at the elbow joint. The patient is asked to resist the internal rotation force.
Yergason test
– increased pain in the area of the intertubercular groove with resistance to supination of the forearm.
Positive "anxiety" test
performed by passive abduction and external rotation of the arm.
If pain occurs and intensifies, the patient seeks to stop the study. Characteristic of internal impingement syndrome .
Gerber-Krushell test
– the patient places both arms behind his back in a position of internal rotation, and then raises them along the back. Informative in case of rupture of the subscapularis tendon.
With positive Hawkins-Kennedy, painful arch, and infraspinatus tests, the likelihood of impingement syndrome is greater than 95%. If these tests are negative, the probability is less than 24%.
Diagnostic confidence can be increased using the lidocaine test. A decrease in the severity of symptoms when performing provocative tests after an injection of lidocaine is confirmation of impingement syndrome .
The leading method is MRI, radiography of joints, ultrasound.
A sore shoulder can become impingement syndrome
Many people suffer from shoulder pain. Faced with this, many people “sin” their joints, sometimes requiring treatment of the back muscles.
Meanwhile, such pain is not always inflammation and joint disease. Sometimes this indicates negative changes in the moving zone. This area is located between the acromion and the cuff of the shoulder joint. What do the changes mean? The space under the acromion is minimized. As a result, inflammation occurs. The affected ozone is the joint capsule. And all this is called impingement syndrome.
What kind of painful syndrome is this: the most common causes of the disease
IS is a serious disease. It has its reasons. For the syndrome to develop, the following negative phenomena must be present. So, the reason may be a person’s professional activity. At risk are people who carry heavy physical loads, those who are often forced to hold their arms above their heads. This is a specialty such as installers, painters, finishers.
Athletes playing volleyball, basketball, badminton. If a person is involved in strength sports, pressing dumbbells or discs, this can also be the cause of the disease.
Impingement may occur as a result of accidents, tendon injuries, arthrosis of the shoulder joint, or calcific tendinitis.
If a person has to raise his arm above his head slightly to the side, he may feel unpleasant, strong painful sensations. And if he needs to do work with his hands raised, then this becomes completely impossible. Because the victim is in extreme pain.
For the distance between the rotator cuff and the acromion to narrow and cause pain, the development of symptoms and certain factors are required. Today doctors talk about the types of impingement syndrome into which the disease is divided.
Functional. If the work of the brachial muscle extends to the shoulder cuff, IS begins to appear. After all, muscle control is not ensured. And although there are no muscle diseases, they are healthy, nevertheless, the syndrome develops.
Structural. The narrowing of the distance may also appear due to other changes. With this type, changes occur in tendons, ligaments, and bones. They suffer from joint capsules. The cause may be chronic inflammation or thickening of the ligaments. Also - subacromial spurs can be affected, as well as wear and tear of the acromioclavicular joint.
The disease and its symptoms
There are a lot of tendons in the human shoulder that are closely connected to each other. The largest number of them is located under the acromion. And painful sensations may appear if you move your hand one way or another.
Tendons become pinched or ruptured – the person experiences pain. This can happen due to intense physical activity and certain postures (arms above your head).
Inflammation persists and other symptoms may occur.
If the synovial bursa between the rotator and acromion is irritated, the person will experience pain at night. And these sensations will greatly torment the patient, depriving him of sleep in a certain position.
Also, a sore shoulder will limit a person’s movements. The shoulder will move poorly and cause discomfort until the symptoms go away. In medicine, this condition is called frozen shoulder. And such pain can become chronic.
Treatment of the inflammatory process
If the disease is at an early stage, then several measures are sufficient:
Firstly, these are gymnastics and exercises aimed at prevention. Of course, you will need painkillers and drugs that act to extinguish the inflammatory process. You need to do injections.
A sore shoulder needs rest and rest; you should not make painful movements: lifting and twisting your arms.
You can't start a disease. If symptoms appear and the disease is diagnosed, immediate treatment measures must be taken. If this is not done, it will be difficult to sleep at night, the disease will become chronic, and it will be difficult for the person to rotate his arm or lift it. Hands become weak. Doctors may observe rotator cuff tears and joint stiffness.
If the disease develops, prompt surgical assistance will be needed.
The final treatment will be prescribed by specialists.
They analyze the causes, possible and optimal treatment methods. Doctors may prescribe conservative treatment. This may also include physical therapy, shock wave and ultrasound treatments. Doctors may also recommend courses of massage and thermotherapy. Author: K.M.N., Academician of the Russian Academy of Medical Sciences M.A. Bobyr
Treatment of impingement syndrome
The treatment complex includes: competent therapeutic exercises (mainly exercises aimed at stretching muscles), mandatory night splints with shoulder abduction, physiotherapeutic treatment, blockades with steroids.
Surgical treatment, arthroscopy (three main options): only treatment, consisting of sanitation of the tendon and attachment site; treatment in combination with acromioplasty and restoration of tendon integrity in combination with acromioplasty. Repair of collateral damage.
According to Azar, the concept of acromioplasty includes:
- resection of the acromiocoracoid ligament;
- removal of the anterior lip of the acromion;
- removal of the anterior part of the acromion to the anterior edge of the clavicle;
- resection of 1-1.5 cm of the acromial end of the clavicle in the presence of pronounced arthrosis changes in the acromial clavicular joint.
Postoperative rehabilitation takes up to 3 months and depends on the presence of concomitant pathology in the joint and the extent of surgical intervention.
Subacromial (impingement) syndrome
About the article
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Regular issues of "RMZh" No. 8 dated April 29, 2005 p. 545
Category: General articles
Author: Belenkiy A.G.
For quotation:
Belenky A.G. Subacromial (impingement) syndrome. RMJ. 2005;8:545.
Attempts to seriously study periarticular lesions of the shoulder joint have always revealed the heterogeneity of the clinical forms of this pathology and the inconsistency of combining them into one disease. Soft tissue lesions of the shoulder area were actively studied by orthopedists, rheumatologists and neurologists, bringing to the vision of the problem ideas specific to each of these specialties. Currently, there is a certain consensus regarding the classification of periarticular lesions of the shoulder joint, which is reflected in the exclusion from practical use of the general term “humeral-scapular periarthritis” as clearly outdated.
A reflection of the orthopedic (biomechanical) view of non-traumatic pathology of the tendon apparatus of the shoulder joint is the concept of Neer (1972), who introduced the term subacromial impingement syndrome into practice. Neer postulated that the cause of the pathology is an imbalance between the stabilizer and depressor muscles of the head of the humerus (supraspinatus, infraspinatus, subscapularis and biceps humerus), which leads to a decrease in the space between the head of the humerus and the acromion (Fig. 1), and, as a result, , to chronic injury to the tendons of the rotator cuff muscles during movements. Neer considered the degenerative-inflammatory process of the tendon apparatus of the shoulder joint as a staged process, ultimately leading to complete tendon ruptures. The process involves structures located between the head of the humerus, the anterior-inferior surface of the acromion and the coracoacromial ligament, which include the tendons of the supraspinatus, infraspinatus, subscapularis muscles, the long head of the biceps and the subacromial bursa with secondary involvement of the clavicular-acromial joint. The most vulnerable structure in this area is the supraspinatus tendon. The muscle is responsible for stabilizing (centering) the head of the humerus during shoulder abduction under the influence of the powerful deltoid muscle (Fig. 2). The author, based on a comparison of morphological and clinical data, proposed a classification of damage to the tendons of the rotator cuff as a stage of subacromial syndrome: I – swelling and hemorrhages in the tendons; II – fibrosis, thickening of the tendons, the appearance of partial tears in them (Fig. 3); III – complete tendon ruptures, degenerative bone changes involving the lower surface of the acromion and the greater tubercle of the humerus. Neer believed that in 95% of cases, “spontaneous” ruptures (including “creeping”) of the rotator cuff and long head of the biceps tendons are the result of progression of subacromial syndrome. Later, in 1989, Zlatkin identified, based on magnetic resonance imaging data, 4 structural stages of subacromial syndrome: 0 – absence of morphological changes; I – increase in signal intensity from tendons without changes in their thickness and tears; II – increased signal intensity with surface roughness and thinning of the tendons; III – complete rupture of the supraspinatus tendon (or other rotator cuff muscles). Clinical manifestations of subacromial syndrome are signs of multiple lesions of the tendons of the shoulder joint, frequent recurrence of pain and a tendency towards its chronic course. In the clinical diagnosis of subacromial syndrome, the Neer (photo 1) and Hawkins (photo 2) tests are used, which cause compression of the subacromial structures (additional pressing of them by the head of the humerus to the lower surface of the acromion) and thus reproduction of the characteristic pain syndrome. Nir's test. When fixing the scapula of the person being examined with one hand, the doctor raises the patient’s outstretched arm with the other hand at an angle midway between anterior flexion and abduction. In this case, passive compression of the structures under the anterior part of the acromion occurs. Pain when performing this movement indicates subacromial syndrome. Hawkins test. When the patient's arm is bent at an angle of 90° at the elbow and shoulder joints, additional internal rotation is performed in the shoulder joint by forcing pressure on the elbow joint from below. The appearance of pain at this moment indicates damage to the subacromial structures. In addition to functional tests, a test injection of an anesthetic into the subacromial bursa is used in the diagnosis of subacromial syndrome. If after the procedure the pain completely disappears when performing active and passive movements, the diagnosis of subacromial syndrome is considered reasonable. Treatment of subacromial syndrome depends on the severity of clinical manifestations and the stage of the process. In stage I of the syndrome, treatment does not differ from the treatment of simple tendonitis and includes rest, therapeutic exercises, and taking nonsteroidal anti-inflammatory drugs (NSAIDs). When prescribing NSAIDs, both the effectiveness and safety of the drug are taken into account. One of the most effective NSAIDs with a pronounced analgesic and anti-inflammatory effect is aceclofenac (Aertal). The mechanism of action of the drug is the suppression of cyclooxygenase (COX), a key enzyme in the metabolism of arachidonic acid into prostaglandins (PGs). Two isoforms are known: COX-1 and COX-2. A recent study of aceclofenac in inhibiting the activity of COX-1 and COX-2 in human whole blood showed that aceclofenac inhibits both isoenzymes, but predominantly the expression of COX-2 and thus approaches selective inhibition. In addition, aceclofenac also inhibits the synthesis of inflammatory cytokines such as IL-1b, and in this regard, the anti-inflammatory inhibitory activity of aceclofenac has a multifaceted effect on inflammation and pain, suppressing both COX-2 and IL-1b, which makes it the drug of choice for relief pain with subacromial syndrome. At the same time, much attention is paid to the problem of safety when using NSAIDs. First of all, side effects from the gastrointestinal tract are studied, among which all the symptoms that may be associated with this pathology are taken into account. As a result of numerous studies, it has been shown that Airtal weakly inhibits prostaglandins in the gastric mucosa, which is accompanied by fewer side effects from the gastrointestinal tract and better tolerability compared to other NSAIDs. For persistent pain syndrome, subacromial injection of microcrystalline glucocorticosteroids is used (no more than 3 injections per year). Therapeutic gymnastics (isometric) is aimed at restoring the balance of the stabilizer and depressor muscles of the head of the humerus (rotator cuff and biceps brachii). In stage II of the syndrome, which is characterized by a more persistent course, treatment is also mainly limited to conservative methods, but if it is ineffective within a year, surgical methods are also used, including subacromial decompression (intersection of the coracoacromial ligament with anterior acromionoplasty). In stage III, which occurs exclusively in patients over 40 years of age with prolonged pain and is characterized by gross degenerative changes in the tendons of the supraspinatus muscle and the long head of the biceps, the indications for surgical treatment are more justified. Surgical treatment consists of arthroscopic revision of the subacromial space, removal of osteophytes on the lower surface of the acromion, often located in the area of the articular surfaces of the acromial clavicular joint, and restoration of the integrity of the tendons. Thus, subacromial syndrome (shoulder rotator compression syndrome, code M.75.1 according to ICD 10) is one of the forms of degenerative-inflammatory lesions of the tendon apparatus of the shoulder joint, which differs from simple tendinitis by characteristic diagnostic signs. Knowledge of clinical functional diagnostic techniques for shoulder joint pathology, supplemented, if necessary, with data from instrumental methods, allows the doctor to have a differentiated approach to the diagnosis and treatment of a heterogeneous group of diseases of the soft tissues of the shoulder joint area. In the vast majority of cases, it is possible to establish the correct diagnosis in accordance with the modern classification and determine the optimal treatment tactics for the patient. One of the objectives of this publication is to convince doctors of the need to abandon the outdated term “humeral-scapular periarthritis,” which, unfortunately, still continues to be found in the domestic medical literature. Literature 1. Bunchuk N.V. Diseases of extra-articular soft tissues. In a manual of internal medicine. Rheumatic diseases. Ed. V.A. Nasonova, N.V. Bunchuk. –M. Medicine.1997 – pp. 411–428. 2. ICD 10. International statistical classification of diseases and related health problems. Tenth revision. // WHO. Geneva - 1995. - Volume 1., part 3. 3. Calis M., Akgun K., Burtane M. et al. Diagnostic values of clinical diagnostic tests in subacromial impingement syndrome // Ann Rheum Dis 2000; Vol 59.– p. 44–47. 4. Neer CS. Anterior acromionoplasty for chronic impingement syndrome of shoulder. // J Bone Joint Surg 1972; Vol 54A. – p. 41–50. 5. Thornhill TS. Shoulder pain. In: Kelley H. Sledge K. Ed. Textbook of rheumatology. Saunders 1993. – pp. 417–440. 6. Walch G., Noel E., Boulahia A. Rotator cuff tears: epidemiology, differentiation, clinical presentation and natural history // Rheumatology in Europe 1999.– Vol. 28.–N 4.–pp.129–136.
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